Good day and welcome. I'm Rainer Kimmich, gynecologic oncologist from Essen in Germany, and have the honor today to be a party of the first of many new educational offerings from the IGCS. IGCS is committed to providing meaningful opportunities in collaboration with our industry partners through this 12-month educational engagement program. This platform will provide the level of strategic engagement needed to educate and inform gynecologic oncology professionals on current and future medicine and technology treatments for our patients. IGCS will provide multiple touch points that will provide outstanding opportunities for the dissemination of current data and information using influential thought leaders and experts in gynecologic cancer around the world. Joining me today are my friends and colleagues from the Mayo Clinic, both gynecologic oncologists in Rochester, Minnesota. This is Dr. Andrea Mariani and Dr. Kerry Langstroth. We are here to talk about the recent publication by Serena Cappuccio entitled The Shift from Inpatient to Outpatient Hysterectomy for Endometrial Cancer in the United States, Trends, Enabling Factors, Cost, and Safety, where you evaluated trends in outpatient versus inpatient hysterectomy for endometrial cancer and assess enabling factors, cost, and safety. Please Kerry, please could you now introduce your paper in two minutes with respect to the rationale, the results, and interpretation of the data. Thank you for having me here for this discussion today. So in our paper, The Shift from Inpatient to Outpatient Hysterectomy for Endometrial Cancer in the United States, Trends, Factors, Cost, and Safety, we showed that over the last 15 years, there has been a shift from inpatient open surgery to outpatient minimally invasive surgery for the treatment of endometrial cancer. In this study, we really wanted to gain a better understanding of the impact of robotics on patient outcomes and costs of surgical treatment of endometrial cancer in the United States. In this study, we utilized the premier healthcare database to assess trends in hysterectomy for endometrial cancer between January of 2008 to September of 2015. In this database, we observed a shift from inpatient open surgery to outpatient minimally invasive surgery. For instance, in 2008, 70% of our surgeries were done in an open approach, while only 25% were done through a minimally invasive approach. By 2015, this had switched to 26% of our patients undergoing open surgery, while about 65% had minimally invasive surgery. This shift was primarily driven by the adoption of the robot. In 2008, about 10% of cases were done robotically, while in 2015, that had shifted to 60%. As robotic surgery took over, we observed a shift from inpatient to outpatient setting, and we saw an increase from 2% to 40% of outpatient surgery in 2015. During this time, we also found that complication rates remained unchanged and healthcare costs overall decreased. Overall, the study shows that the adoption of robotic surgery has allowed us to transition to primarily minimally invasive surgery and allowed our patients to have outpatient surgery without increasing complications and decreasing healthcare costs. Thank you, Keri, for this excellent overview over this important paper, and may I ask you a first question. In your opinion, what was the specific effect of robotic surgery in this context of rising numbers of outpatient treatment, and what do you think about the robotic technology that facilitated this shift in outpatient? Yeah, good question. So, the adoption of robotic surgery really allowed us to offer minimally invasive surgery to the majority of our patients, and this shift really then allowed outpatient surgery to become feasible. When, you know, if we consider just open approach, most of those patients won't experience outpatient surgery, and in fact, less than 2% of patients that undergo an abdominal approach will be able to go home same day. And this is just a variety of reasons that, you know, open approach has increased pain scores, patients take a little longer to recover. So, you know, I think really that shift to robots and the shift to minimally invasive surgery allowed us to have outpatient opportunities for our patients. And specifically, robot has really transformed the way that we do minimally invasive surgery. When we look back even prior to 2008 and look at the use of laparoscopy, you can see that when we adopted laparoscopy, it became about 20% of our cases, and that remained flat, even after studies like LAP2 came out saying that we can safely treat patients laparoscopically. We still didn't really adopt that technique, and there's many reasons why, you know, but some of that had to do with our risk of conversion, and if you converted, your patients had a higher or have worse complications and higher risk of that outcome. So, you know, I think that robotics really allowed us to offer reproducible minimally invasive surgery. You know, Dr. Mariani likes to say that robotic technology has been disruptive in this field, and it's been disruptive in a very positive way. It has eliminated many of the barriers to laparoscopic surgery or to minimally invasive surgery and made it overall reproducible. Thank you, Carrie, for this convincing arguments. Andrea, may I ask you another question? What was the complication rate in open versus vaginal versus endoscopic surgery with respect to clavin-dindo more or equal than three, and complications of which type? Is there a different spectrum of complications of the 2% readmission rate from out and in-patient treatment respectively? Yes. So, yes. Thank you for this question, and certainly, there was a difference in complication between open and minimal invasive as expected, and the open surgery carried certainly more complication and more severe type of complication. What we see, we see that while we shifted to outpatient, there are less complication and less severe complication. In the open, there are more surgical site infection and more urinary tract infection and more transfusion in the open part of the surgery. Yeah. Thank you, Andrea. So, Carrie, again, the most difficult question now for you, it's about cost. Maybe not applicable to United States of America, but on many countries in the world, what's about cost in countries not adequately reimbursing outpatient treatment? Yeah. I mean, I think that's a struggle. You know, I think we've been fortunate that we are reimbursed substantially in the United States for our outpatient surgeries. I still think that if, you know, I think cost is always an important factor when we look at healthcare, but I do think that the patient outcomes really advocate for a need to shift our approach for treatment of endometrial cancer to minimally invasive, and that we can certainly do that safely by sending them home the same day. So, I do think that there is, you know, some motivating factors here besides just healthcare costs that should be considered. Yes. I would have to add something about this because, again, I come from Italy, so I think I understand also the problem of this. In Italy, I have to say that at least in the past, the government was paying less money to the hospital if patients went home on the same day. And so, hospitals were keeping patients in the hospital more time to receive more money. I don't know if this recently changed, but this is not good and not an incentive to send patients home. So, and unfortunately, in the long term, this approach does not really help advancement and innovation, and it does not help to save resources. It is counterproductive. This is why I believe we really need to lobby the governments, showing them the data and make them understand that this is a type of a myopic type of approach to pay in this way. I don't know how it is in Germany, but I remember in Italy, at least some years ago, this is what was happening. Yes. Thank you, Andrea. I absolutely agree with your opinion. In Germany, it's exactly the problem that you will get least money if you do it on an outpatient. And even if you discharge the patient too early, let's say in the first or second day, you will get less money if you keep them three to five days in the hospital. So, that's really a problem of reimbursement. Now, I would like to ask also Andrea again, are there studies where the patients are happy with the outpatient treatment or they would rather prefer to stay in the hospital for some days? Yes. No, and thank you for this question. In the literature, there are studies about outpatient surgery, mainly with laparoscopic hysterectomy. But in summary, we can say with a few exceptions that the vast majority of the study are concordant to say that patient satisfaction is very high in general, independent from the hospital stay. There is also a recent randomized trial from 2018 from Denmark, in which there are benign patients with the laparoscopic hysterectomy, they describe the patient satisfaction is overall very high and not decreased in patients who have same day discharge. However, one third of patients randomized to same day discharge elected to stay overnight for no medical reasons. Therefore, the limited data seems to say that patients overall they are happy. However, in general, a fraction of them that may be 10% to 30 or even sometimes in some population 50% still elected to stay. Also, in the medical literature, the data are a kind of mix between benign and gynecologic cancer and there are no good data on or very limited data on specifically gynecologic cancer or specifically endometrial cancer, the data overall are limited and so I can tell you something about Mayo Clinic because at Mayo Clinic, we have endometrial cancer patient, we have looked at our population, these are very general type of percentages, so they are not perfect, but about 60% endometrial cancer patient, they go home on the same day. If we look at the last year, about 15% they have an overnight stay. So, for example, a patient who have surgery later in the day may elect to stay overnight and 25% stay more than 24 hours and endometrial cancer patients, patient experience is good or very good in 98% of patients independently from the type of surgery in or outpatient. So, Mayo patient seems happy independently from same day discharge or not. However, last thing, certainly my personal experience, I have to say that I have met a few patients that say that they are uncomfortable or feel unsafe, especially if surgery is later in the day or especially in those few patients that are probably elderly or more vulnerable. Thank you, Andrea. I think this contribution was very important because I think that rather than the outpatient treatment, important is the reduction of complications and the enhancement of life quality by lesser pain and less complications and sequelae. And I think this is the main point why the development of minimal invasive therapy is so important and the secondarily it may have an advantage to send them home earlier. And this is, I think, a big difference between different parts of the world and maybe even in United States. There are some regions where the patients want to have the care as an inpatient and others want to go home as soon as possible. And certainly it may reduce cost if we could send them home earlier. This is one factor, but the main factor is the reduction of complication which enables us to send them home earlier, but not necessarily causes the need of sending them home. So now, Kerry, next question is because we talked now about the past up to now because the study analyzed data of the past. Do you know what is the percentage of outpatient surgical treatment of endometrial cancer in the U.S. today and what is the percentage of open surgery still done? Do you expect a further change for the next five or ten years in United States of America? Yeah, good question. So, you know, when we look now at the more recent data, which has not really been published, but looking at the PREMIER database again, over 60% of surgeries are done out in an outpatient setting. So that's all GYN surgeries. That's not just looking at endometrial cancer. So, you know, it's still, it's gone up from 40% to 60%, so quite substantial increase. You know, looking here at our population here at Mayo, we have transitioned from 25, so about 25% of our patients are inpatient. The same day dismissal rate is 60% in our outpatients, so the patients that stay overnight but go home the next day is about 15%, and 80% of our patients undergo robotic surgery. I don't have the U.S. data to say how many are still done open. Looking at our data, it's about 4% of patients have open surgery. Now, one of the things we didn't look at at this study was why do people have robot or why do people have open surgery? We didn't analyze that all that well, and I think that really is the question for what the future looks like for endometrial cancer. My hunch is that the majority of open surgeries are done because of advanced stage disease, and if that's truly the case, then we do have an opportunity to look at robotic surgery and how it would apply to four-quadrant surgery or large periodic nodes and how we would be able to safely default an endometrial cancer patient, but I do see, I mean, we continue to push the envelope surgically, and I'm sure you do in your practice as well, to try different innovative ways, you know, because really our driver here is to, as you said earlier, to decrease the complication rates of our patients, so I do see that we're going to increase our use of robotics, and I do see the opportunity to move more towards outpatient surgery as an option in the future. Thank you. Now, let's think about the future a little bit. Now, we found, following your study, but also with other studies in the world, that robotic surgery enhances the ability to do minimal invasive surgery, even in more difficult situations, to reduce with this approach the complications to enhance life quality and to enhance also outpatient treatment. This is directly beneficial to the surgeon, maybe to the hospitals because of lower cost, and at the end for the system, but this is just to optimize a little bit the medical treatment or the surgical treatment. On the other hand, robotic surgery opens so many other aspects of digitalization of the world, and what do you think will be the factors which robotic technology could influence for the future? Do you think it will remain just to bring the patients earlier at home, or are there other advantages you already see, but maybe not completely established, which will make robotic surgery maybe the standard of treatment in the future for a lot of different diseases? Yeah, I think, you know, we've seen some advantages already, you know, with sentinel nodes and endometrial cancer. It's a pretty simple example, but using indecisive and green for and fluorescent lights provided by the robot to really just do sentinel node procedures, and I think we would have done sentinel nodes even if we wouldn't have had the robot in ICG, but I do see different technologic advantages to being able to have that technology. There's also, you know, in other cancers, so in lung, for instance, they're looking at using image-guided resection and a robot, and certainly those types of advances, I think, you know, could potentially be applicable to GYN cancers in the future, but yeah, I think, I mean, I think there's a lot of advantage and a lot of things that we could adopt with a robot and look to the future to better our patient treatment. I don't know if Andrea has any. Yes, Andrea, yeah, I'm sure he has, but I want just to ask an additional question. Andrea, could you also tell us a little bit about maybe changes in education using the robot, because we know all the pilot school with flying an airplane without really flying it, and we know the driver school where the driver and the teacher are sitting side by side and so on. Could you just tell us, did this really change the education, the learning curve or whatever? Yes, so thank you for asking that, because frankly, I was thinking when we were speaking about cost and saving cost, if we think about the cost for teaching and preparing a surgeon for independent practice, the fact that robotic, for example, in comparison to laparoscopy allows surgeons to be prepared with a much faster learning curve. First of all, this is already an advantage with education. Second, all the technology, how the technology can introduce ideally feedback with education. So think about, I'm just thinking about the future, but AI technology, if with AI technology we can start to put together a kind of a feedback of the robot, like right now when we are driving the car, we receive a feedback if we are going on the wrong lane. So think about a visual feedback that the resident can receive. Okay, now you are going in not in a safe space or 80% of surgery or 90% of surgery, they do this. And now there is a visual message that you are going in the wrong direction. You can still decide to go there, like when you receive the feedback. But I think there is an incredible potential in technology. So frankly, the future is really into robotic surgery and the possibility to develop this type of technology in also into the education. Andrea, I think you really convinced me that robotic surgery is not only to make it less complicated, easier to do the surgery, but has additional benefits which may make in the future maybe more rapidly educated surgeons, more standardization of surgery, more control, more scientific research in that. And at the end, maybe in fact, better surgery and better data. So I thank you all for first for doing this study and presenting today to show us the first step that we can say it seems to be beneficial not only to the patients, but also to the hospitals. If we implement robotic surgery, and even with respect to the cost, at least if we get it adequately reimbursed. But secondarily, and I think this is 90% of the chance of the future, it brings so many aspects of the artificial intelligence of the digital life of the future that we will a lot more to see in the future. I thank you again very much for this webinar and hope to see you soon again. Thank you. Thank you. Thank you.

gynecologic oncologist

educational offering

minimally invasive surgery

robotic surgery

patient outcomes

surgical standardization